The practice of pediatrics emerged as a specialized domain of clinical medicine inthe late nineteenth century. When the unique health needs of children were formalized through the establishment of the American Academy of Pediatrics in 1930,infection was the most prevalent threat to child survival, and infant feeding practiceswere a central focus of primary care. In the latter half of the twentieth century,developmental and behavioral difﬁculties constituted a growing percentage of the

problems being brought to the primary care setting. Within this changing context,Richmond (1967) identiﬁed child development as the “basic science of pediatrics”and Haggerty, Roghmann, and Pless (1975) coined the term “new morbidities” todescribe the seismic shift in parental concerns about their children’s well-being.As we now move through the second decade of the new millennium, increasingattention is being directed toward the adverse impacts of a host of social, behavioral,and economic threats to child health and development. As our recognition of thesecontextual factors has grown, our understanding of the critical inﬂuence of thechild’s environment of relationships has deepened. This expanding knowledge hasgenerated increasingly greater demands for the pediatric primary care setting toaddress the immediate and long-term consequences of signiﬁcant sources of ongoing stress, including poverty, racial and ethnic discrimination, maternal depression,parental substance abuse, and family and neighborhood violence, among manyother disadvantages.In 2012, the American Academy of Pediatrics issued a technical report (Shonkoff,Garner, The Committee on Psychosocial Aspects of Child and Family Health,Committee on Early Childhood, Adoption, and Dependent Care, & Section onDevelopmental and Behavioral Pediatrics, 2012) and an associated policy statementon toxic stress and the role of the pediatrician. The policy statement, which is citedfrequently in this book, included the following bold statement: “Although the impactof these ‘new’ morbidities on pediatrics, public health, and society in general is nolonger in question, the professional training and practice of pediatricians continuesto focus primarily on the acute medical needs of individual children. The pressingquestion now confronting contemporary pediatrics is how we can have a greaterimpact on improving the life prospects of children and families who face thesev

vi

Foreword

increasingly complex and persistent threats to healthy development” (AmericanAcademy of Pediatrics, Committee on Psychosocial Aspects of Child and FamilyHealth, Committee on Early Childhood, Adoption, and Dependent Care, Section onDevelopmental and Behavioral Pediatrics, Garner, & Shonkoff, 2012).The challenges presented by this changing context have stimulated the evolvingdevelopment of the ﬁeld that is the subject of this book—integrated early childhoodbehavioral health in primary care. As stated by Rahil Briggs at the end of the ﬁrstchapter, this broader approach to health promotion and disease prevention for youngchildren provides “much needed services in the only universally accessed and nonstigmatized setting we have for very young children.” Its origins lie at the intersection of three complementary bodies of work that have generated growing attentionover the past two decades. The ﬁrst is the reported association between adversechildhood experiences (ACEs) and adult disease. The second is the concept of toxicstress, which refers to the physiological disruptions produced by excessive activation of stress response systems which can have a “wear-and-tear” effect on the brainand throughout the body. The third is the notion of trauma-informed care, whichprovides a framework for treating individuals who have had signiﬁcant exposure toviolence, loss, or other emotionally harmful experiences. Taken together, ACEscores quantify increased risk (but not a diagnosis) of health problems; toxic stressfocuses on causal mechanisms that link adversity to impairments in learning, behavior, and health; and trauma-informed care provides guidelines for effective treatment. Building on their diverse origins in epidemiology, biology, and clinicalpractice, these three bodies of work inform an enhanced framework for pediatricprimary care that is the focus of this important book.Throughout this volume, Briggs and her colleagues provide a rich compendiumof practical information about this evolving ﬁeld of practice. The contributingauthors bring different sets of lenses to a common agenda and share a wealth of lessons learned from their own experiences “on the ground.” Beyond its immediateutility for the primary care community, this book also provides a valuable benchmark for current best practice as a starting point (not a ﬁnal destination) for addressing contemporary health problems. With this latter goal in mind, advances inneuroscience, molecular biology, and epigenetics constitute a new basic science forpediatrics—and offer a rich resource for those readers who wish to push the leadingedge of behavioral health even further and create a twenty-ﬁrst century model ofprimary care for young children.

The Basic Science of Early Childhood Behavioral HealthBuilding on a well-established, multidisciplinary knowledge base that has beenbuilt over more than half a century, advances in the biological, behavioral, andsocial sciences have generated the following core concepts that currently constitutea credible basic science for guiding policies and programs focused on health

Foreword

vii

promotion and disease prevention, as well as for informing early childhood behavioral health more speciﬁcally:• Brains are built over time, and a substantial proportion is constructed during theearly years of life. The architecture of the developing brain is built through anongoing process that begins before birth, continues into adulthood, and establishes either a sturdy or a fragile foundation for a lifetime of health, learning, andbehavior.• The interaction of genes and experiences shapes the circuitry of the developingbrain. Scientists have discovered that the experiences children have early inlife—and the environments in which they live—not only shape their developingbrain architecture but also affect how genes are turned on and off and evenwhether some are expressed at all.• Children develop in an environment of relationships that begins in the family butalso involves other adults who play important roles in their lives, such as providersof early care and education, extended family members, physicians, nurses, socialworkers, coaches, and neighbors. These relationships affect virtually all aspects ofdevelopment—intellectual, social, emotional, physical, and behavioral.• Skill begets skill as brains are built in a hierarchical fashion from the bottom up,with increasingly complex circuits building on simpler circuits and increasinglycomplex and adaptive skills emerging with age. Times of exceptional sensitivityto the effects of experiences on different brain circuits are called critical or sensitive periods. These periods begin and end at different ages for different parts ofthe brain.• Cognitive, emotional, and social capacities are inextricably intertwined in thearchitecture of the brain, and the circuitry that affects learning and behavior isinterconnected with physiological systems that affect health. The brain is ahighly integrated organ and its many functions operate in a richly coordinatedfashion. All human capabilities and both physical and mental well-being developthrough a lifelong process that is deeply embedded in the function of the brain,cardiovascular, immune, neuroendocrine, and metabolic systems.• Research on the biology of stress shows how major adversity, such as extremepoverty, abuse, or neglect, can “get under the skin” and result in physiologicaldisruptions that affect lifelong outcomes in learning, behavior, and health. Thisrapidly advancing science can help us identify preventive measures to avoidthese negative effects and can inform more intensive treatment options to counterbalance the problems that are caused by early and more severe adversity.• Toxic stress responses can lead to lifelong impairments in health and development. Learning how to cope with adversity is an important part of healthy childdevelopment. When a young child’s stress response systems are activated withinan environment of supportive adult relationships, the responses are either positive or tolerable, and the result is the development of a well-functioning stressresponse system. When the stress response is activated continually or triggeredrepeatedly by multiple threats in the absence of adult support, it can be toxic andhave a cumulative toll on a child’s physical and mental health for a lifetime.

viii

Foreword

• Problems in cognitive, social, and emotional development, as well as impairments in physical and mental health, often result from complex interactionsbetween a child’s genetic predisposition and his or her exposure to signiﬁcantadversity. These kinds of interactions early in life can prime neurobiologicalstress systems to become hyperresponsive to adversity. This response can createan unstable foundation for development in general, and for physical and mentalhealth speciﬁcally, that endures well into the adult years.• Brain plasticity and the ability to change behavior decrease over time because theincreasing specialization of the maturing brain makes it both more efﬁcient andless capable of reorganizing and adapting to new or unanticipated challenges.Although windows of opportunity for skill development and behavioral adaptation remain open for many years, trying to change behavior or build new skillson a foundation of brain circuits that were not wired properly when they wereﬁrst formed requires more work for both individuals and society.• Positive early experiences, consistent support from adults, and the developmentof adaptive skills can counterbalance adversity and build resilience. The connection between adverse early life experiences and a wide range of costly socialproblems, such as poor school achievement, low economic productivity, criminalbehavior, and impaired health, is well documented. Understanding why somepeople develop the adaptive capacities to overcome signiﬁcant disadvantagewhile others do not is key to enabling more children to experience positive outcomes and build a more resilient society.

Current Best Practices and the Future of Behavioral Healthin Primary CareBecause developmental and behavioral problems in childhood can have lifelongeffects on both physical and mental health, addressing these concerns early in life isa fundamental pediatric responsibility. The principles and practices described in thisvolume represent an important leading edge in the delivery of primary healthcare—and this book serves as a valuable resource for a range of disciplines involved inservices for young children and their families as well as in training the professionalswho deliver those services.The challenges facing integrated early childhood behavioral health in the primary care setting mirror the challenges that have confronted the broader ﬁeld ofearly childhood policy and practice for half a century—from child care and earlyeducation to family support programs and child welfare services, among many others. On the positive side, multiple interventions have been developed to address theorigins of disparities in early development and later school achievement, and extensive program evaluation research has documented both positive impacts for manyprogram participants and strong economic returns for society. Without minimizingthe importance of these documented beneﬁts, however, it is essential that we

Foreword

ix

acknowledge that the quality of implementation when programs are taken to scaleis highly variable, the magnitude of effects typically falls within the small to moderate range, and long-term sustainability of short-term gains has been difﬁcult toachieve. Unlocking the answers to these challenges and producing breakthroughoutcomes require that we apply new insights from both cutting-edge science and thekind of practical, on-the-ground experience catalogued in this book (Shonkoff &Fisher, 2013).The full promise of an integrated approach to behavioral health in primary carepractice lies in the considerable work that remains to be done if we truly want totransform the lives (and future life prospects) of children and families facing signiﬁcant adversity. That quest begins with the simple yet powerful recognition thateffective interventions require resources and expertise that match the challengesthey are asked to address—and different precipitants of toxic stress often requiredifferent responses from a variety of systems. Achieving greater understanding ofvariations in susceptibility to adversity and determining the appropriate mix of strategies to capitalize on existing strengths and address unmet needs are critical challenges that must be addressed.The general question of whether a speciﬁc intervention “works” on average hasguided early childhood policy and practice for decades. In order for integratedbehavioral health to achieve greater impacts in the context of primary healthcare, itis essential that leaders in the ﬁeld begin to focus more explicitly on two criticalquestions. First, what kinds of concerns in what kinds of children and families arebeneﬁtting the most (and why) from speciﬁc practices that are being implementedin the pediatric setting? Second, and equally important, what kinds of problems inwhat kinds of contexts are responding the least or not at all—and why? Identifyingthe former will provide a powerful knowledge base for replication and targeted scaling that will drive the growth of this important ﬁeld. Focusing on the latter muststimulate a search for new intervention strategies that draws on the collectiveinsights, expertise, and experiences of practitioners, researchers, program developers, and parents whose children’s needs are not being fully met. In the ﬁnal analysis,signiﬁcantly larger impacts will be achieved for larger numbers of children andfamilies if advances in scientiﬁc knowledge are leveraged to drive the design, testing, and scaling of a diversiﬁed portfolio of well-deﬁned services that are matchedto available resources, identiﬁed needs, and speciﬁc outcomes for different groupsof children and families.One additional piece of the impact evaluation puzzle that must be put into placeto complete the story presented throughout this volume is the need to raise the baron goals and expectations for integrated behavioral health for young children. Thewealth of baseline information derived from two decades of implementation andevaluation of the Healthy Steps program provides a useful place to begin this task.As described in this book, an expanded and more vigorous approach to screeningand intervention within a relationship-based model of primary healthcare can produce a wide range of impacts on parents’ knowledge about child development,child-rearing practices in the home, and short-term effects on reported child behaviors.

x

Foreword

In addition, participating families reported high levels of satisfaction with the services they received and they engaged more consistently with their child’s pediatricpractice. What remains to be done is a more segmented approach to assessingimpacts on two key objectives—what kinds of concerns and needs are served wellby the current service model and what kinds of problems require far more effort andspecialized expertise than the pediatric primary care setting can be expected to provide? This need for greater differentiation among children and families facingadversity is arguably one of the most important challenges facing the ﬁeld—and itis unquestionably the most important challenge facing those who seek to serve children and families who are bearing the greatest burdens of disadvantage in the earliest years of life.Finally, it is clear that the early childhood origins of impairments in learning,behavior, and health often lie beyond the walls of the medical ofﬁce or hospital setting. Indeed, for many young children, the boundaries of pediatric concern mustmove beyond the domain of medical services and expand into the larger ecology ofthe community, state, and society. Although the responsibility for these larger andexceedingly more complex challenges does not rest solely on those healthcare providers who are focusing on the integration of behavioral health expertise into primary care, the leading edge of this important ﬁeld offers a vital source of expertiseand experience to fuel fresh thinking and new ideas. Briggs and her colleagues haveproduced a book that provides an important starting point for taking on this challenge. The time is long overdue for the entire pediatric community to join in thisjourney.Cambridge, MA, USA

Shonkoff, J. P., Garner, A. S., The Committee on Psychosocial Aspects of Child and Family Health,Committee on Early Childhood, Adoption, and Dependent Care, & Section on Developmentaland Behavioral Pediatrics. (2012). The lifelong effects of early childhood adversity and toxicstress. Pediatrics, 129(1), e232–e246.

Acknowledgments

Dr. Briggs wishes to acknowledge the patients and families who guide our work,motivate us to improve our models of care, and remind us of the importance of gettingit right, for generations present and future.

The Economics of Child Development ..................................................Andrew D. Racine

4

The Goodness of Fit between Evidence-Based Early ChildhoodMental Health Programs and the Primary Care Setting ....................Dana E. Crawford and Rahil D. Briggs

5

6

Healthy Steps for Young Children: Integrating BehavioralHealth into Primary Care for Young Childrenand their Families....................................................................................Margot Kaplan-Sanoff and Rahil D. BriggsWorkforce Development for Integrated Early ChildhoodBehavioral Health ...................................................................................Rebecca Schrag Hershberg and Rahil D. Briggs

Rahil D. Briggs Psy.D. is associate professor of pediatrics at Albert EinsteinCollege of Medicine, director of Healthy Steps at Monteﬁore, and the director ofPediatric Behavioral Health Services at Monteﬁore Medical Group. Dr. Briggsjoined Einstein and Monteﬁore in 2005 as the director and founder of Healthy Stepsat Monteﬁore. She was appointed assistant professor of pediatrics in 2008 andexpanded the Healthy Steps program to multiple sites within Monteﬁore MedicalGroup in 2009 and 2013. She was named the director of Pediatric Behavioral HealthServices at Monteﬁore in 2013 to spearhead the formation of one of the most comprehensive integrated pediatric behavioral health systems in the nation. Her workconcentrates on co-location of mental health specialists within primary care pediatrics, with a focus on prevention, early childhood mental health and development,and parent–child relationships. Dr. Briggs completed her undergraduate work atDuke University (magna cum laude) and her doctoral work at New York University.

exclusively on the provision of integrated behavioral healthcare services in the adultprimary care setting (Hunter, Goodie, Oordt, & Dobmeyer, 2009). Therein, they provide a comprehensive description of the continuum of care between collaborative,co-located, and integrated. They note that collaborative care often refers to agreements between providers, working in separate systems and facilities, to exchangeinformation about shared patients. Co-located care takes that relationship a bit further and often has those same providers, still employed by separate systems, but nowworking alongside each other in a shared facility. Finally, integrated care is providedby a team of providers, employed and working in the same system, using one treatment plan, a shared medical record, and truly functioning as a patient care team.The other area to define is what we mean by “early childhood” when referring toprograms and providers. While one chapter in this volume describes the workforceissue at length, and another describes various programs, we generally refer to the “earlychildhood” period as anything starting either prenatally or around the birth of the child,and depending on resources, it may extend through child age 3, 5, or even 8. Finally,we note that “pediatric practice” refers to any medical professional caring for children,including Family Medicine and Nurse Practitioner colleagues.In this volume, we review questions of program design and workforce development, discuss issues of evaluation and financial sustainability, and share our extensive lessons learned via reports from early childhood behavioral health and pediatricproviders with experience in these models of care. We provide “on the ground”examples whenever possible to illustrate real world application of the topics presented, and create a tone less theoretical and more pragmatic where possible.The organization of the volume was driven by the significant number of requestsfor consultation received since we started our integrated early childhood programming over 10 years ago. In increasing numbers, we have received multiple calls ande-mails, first every few months and more recently on a weekly basis. Other hospitalsystems and community mental health agencies have wanted to know everything fromprogram design to staffing ratios, as they seek to move into this exciting new field. Wehope this volume helps answer many of the questions from our colleagues, and spreadsthe answers more quickly than possible during individual calls and meetings. Let therevolution in integrated early childhood behavioral health programming begin!The first section of the book features chapters focused on two important aspects ofthe “why” that we believe bear emphasis. We do not attempt to comprehensively reviewthe scientific rationale behind addressing early childhood behavioral health, as that hasbeen done quite succinctly by Shonkoff and colleagues, referred to in the foreword ofthis volume. Instead, we focus first on Adverse Childhood Experiences (ACEs)/traumainformed care and, second, on return on investment (ROI) and cost-effectiveness evaluations. In the proverbial three legged stool of helping healthcare systems get behindintegrated early childhood behavioral health with real dollars and commitment, thebrain science is critical, but should be augmented by the long-term health outcomes ofthe ACEs research and the cost-effectiveness of early childhood programming.To begin, Murphy et al. address the American Academy of Pediatrics’ policystatement on the need to address toxic stress within primary care pediatrics. Buildingon the vast legacy of ACEs literature, and their own unique innovations around

1

Introduction

3

ACEs, Dr. Murphy and colleagues paint a compelling picture of the power of theintergenerational transmission of trauma, and the ways in which an integrated primary care practice might address this critical public health issue. Rather than aunique, isolated phenomenon, the authors demonstrate that ACEs are in fact a common occurrence, have a large impact on parental functioning, and are a key target ofintervention in this arena. Although some pediatric practices have waded into theACEs waters, there is still significant apprehension around addressing ACEs in primary care, despite the powerful reasons to do so. The chapter highlights four commonly heard concerns: provider discomfort around ACEs, perceived misalignmentbetween asking parents about their own childhood during a pediatric visit, theresponsibility of mandated reporting regarding ACEs, and the need for follow-upcare upon discovery of ACEs. In each area of concern, the authors provide richexperience-based responses to facilitate integration of ACEs and trauma informedcare into primary care pediatrics, particularly focused on the early childhood domainand the parent–child relationship.The second chapter in this section addresses the remarkable ROI when we intervene early, and the reasons to do so from an economics perspective. Via applicationof human capital theory to the arena of early childhood development/behavior,Andrew Racine paints a sophisticated picture of the interplay between these twofields. Dr. Racine is uniquely qualified to address this topic, as both a pediatricianand an economist, and helps outline the empirical findings related to economic evaluations of early childhood programs. Although most readers will be familiar withthe usual suspects of ROI in early childhood (Perry Preschool, Abecedarian, etc.),the chapter goes beyond a summary of these findings to identify important considerations in conducting future cost-effectiveness evaluations that can potentially beapplied to a wide range of integrated early childhood behavioral health programs.Finally, the chapter concludes with policy implications, noting the limit of relyingsimply on economic markets to encourage programming. Dr. Racine suggests thatthe “illumination of the neurological and molecular biological mechanisms influencing the developing brain, coupled with an accumulation of persuasive empiricalevidence regarding the economic benefits of investing in early child development, isshifting social perception toward an acknowledgment that the time has come toredefine public responsibility toward fostering the human capital stock of the nextgeneration of citizens.”From a brief foray into the “why,” we move to the most substantial part of thevolume, the “how/what,” comprising seven chapters that aim to guide anyone—from practitioners to policy makers—through the various important design considerations that play a role in the creation and implementation of integrated earlychildhood behavioral health programs.We begin with an attempt to quantify the “goodness of fit” between the majorevidence based early childhood behavioral health interventions and primary care.This chapter was written by Crawford and Briggs in recognition that, simply becausea program has an evidence base in one setting, it does not mean it will necessarily bea good fit within another setting. Primary care is a unique venue, and families interface with primary care differently than they might a mental health clinic or other

4

R.D. Briggs

locale. For example, primary care treatment is episodic and needs-based, rather thandivided into weekly sessions scheduled in advance, as might be the case in a behavioral health clinic. Furthermore, the primary care environment is a fast paced, multidisciplinary setting focused on improving care while reducing costs. Thus, long-termtreatments, or programs that are especially costly to implement, may not be ideal or,even, appropriate. This chapter focuses on seven points we deem critical when determining the goodness of fit between a particular program and primary care and concludes with programmatic recommendations for early childhood integrated care.Next, Kaplan-Sanoff and Briggs describe The Healthy Steps program, the original early childhood evidence based intervention specifically designed for integration into primary care settings, including the history, the cornerstones of theintervention model, lessons learned, and challenges encountered during the replication phase. The chapter closes with a look toward the future, as Healthy Steps hasrecently (2015) joined forces with ZERO TO THREE, which has secured fundingto examine effective replication, sustainability, and scalability pathways for theHealthy Steps model. The goal is to build the capacity and infrastructure of theNational Healthy Steps Office at ZERO TO THREE to design a blueprint for thenext stage of growth and evaluation.The second part of this “what/how” section focuses on workforce development/training, challenges in integration and the silos that resist change, the need to focus onculturally relevant interventions, and reimbursement and evaluation of programs.To begin, Hershberg and Briggs discuss the workforce development and trainingneeds for providers of early childhood behavioral healthcare in an integrated setting. We first address the unique tasks and requirements of the job, and the skills andabilities that are needed to do the work most effectively. We then explore the goodness of fit between certain fields of study (such as social work, nursing, and psychology) and integrated early childhood behavioral healthcare. We look at thequalities and traits needed in order to function successfully in primary care, andargue that successful practitioners will focus on both provision of patient care andculture and practice change, and we conclude with a focus on the need for continualtraining and ongoing focus on quality.The idea of culture and practice change is a salient one for effective wide scaleprovision of integrated early childhood behavioral health programming. Briggs,Germán, and Hershberg discuss issues of silos and integration challenges via areview of our decade of integrated early childhood behavioral healthcare experienceat Montefiore Medical Center in the Bronx, NY. Constantly infusing lessons learnedand reasons for programming decisions, we present our current program model(including setting, population served, and design). We discuss our use of universalACEs screening to best identify families who might benefit from our services, andreview the many steps and mistakes made along our journey toward arriving at thisdesign. We review our universal screening schedule for young children and theircaregivers and present our two tracks of intervention: intensive services for thosefamilies most at risk, and short-term behavior and development consultations for thegeneral population. We also discuss our unique parental mental health programming,and the benefits of providing treatment for parents within the pediatric setting.